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PEDIATRIC
RHINOSINUSITIS
DANIEL W. TODD, MD, FACS
MIDWEST ENT
“GET REAL”
WHAT IS CHRONIC
RHINOSINUSITIS VS
THE NORMAL
“SNOTTY NOSE” KID?
MUST BALANCE THE
SELF LIMITED
NATURE OF THE
DISEASE ITS
SIGNIFICANT
MORBITITY.
Rhinosinusitis
A GROUP OF DISORDERS
CHARACTERIZED BY
INFLAMMATION OF THE MUCOSA OF
THE NOSE AND PARANASAL
SINUSES
THERE IS NO CRITERIA BASED ON
ETILOGY
RHINOSINUSITIS
REALLY AN IMFLAMMATORY
DISORDER
NEED TO STOP THINKING OF IT AS
SOLEY AN INFECTION (INFECTION IS
REALLY THE RESULT)
Rhinosinusitis
Rhinosinusitis is the preferred
terminology as you DON’T get the
sinusitis without the rhinitis.
The term is then further defined by the
duration of the inflammation
ACUTE – LESS THAN 4 WEEKS
RECURRENT ACUTE
CHRONIC-MORE THAN 12 WEEKS
FORM AND FUNCTION
FORM (ANATOMY)
FUNCTION
(PHYSIOLOGY)
ANATOMY (FORM)
DEVELOPING SINUSES
PHYSIOLOGY
(FUNCTION)
NASAL PASSAGES
SINUSES
BREATHING
WARMING
FILTERING
HUMIDIFYING
OLFACTION (SENSE OF
SMELL)
RESISTANCE
LIGHTEN THE SKULL
MUCOUS PRODUCTION
HUMIDIFICATION
PROTECT FROM FALCIAL
TRAUMA
PROTECT NASAL
BAROTRAUMA
VOCAL RESONANCE
ENHANCE OLFACTION
RHINOSINUSITIS---HOW
DO YOU GET IT
INFLAMMATION--BLOCKING OF THE
OSTIA—DIMINISHED
PH---MUCOCILIARY
DYSFUNCTION---STAGNATION OF
SECRECTIONS--OVERGROWTH OF
BACTERIA OR
FUNGUS
RHINOSINUSITIS
INFLAMMATION
CAUSED BY: ?
OMC: AREA OF
RELATIVELY TIGHT
ANATOMY
CAUSATIVE FACTORS:
URI’S---CHILDREN
CAN GET 6-8-10
“COLDS” YEAR
AND 5-10% CAN
BE COMPLICATED
BY ARS
CAUSATIVE FACTORS
BACTERIAL
PATHOGENS:
BIOFILMS
SUPERANTIGENS
(RELATIONSHIP
WITH ATOPIC
DERMATITIS)
HIGH MOLECULAR
WEIGHT
PYROGENIC
PROTEINS
ELICIT
EXTREMELY
POTENT
STIMULATORY
EFFECT ON TLYMPHOCYTES
SUPERANTIGENS
BACTERIA (staph aureus, pseudomas,
H influenza)
FUNGI (Molds, Candida, Bipolaris,
Alternaria, Aspergillosis)
Allergens (Conventional and Bacterial
antigens)
Irritants
CAUSATIVE FACTORS
ALLERGIES:
INHALANT AND
INGESTANT---6090% OF SURGICAL
PTS HAVE
SIGNIFICANT
ALLERGIES ON
SKIN TESTING
CAUSATIVE FACTORS
ADENOIDITIS--PHARYNGEAL TONSIL
CAN OFTEN SERVE
AS A BACTERIAL
RESERVOIR
75% OF PEDIATRIC
CRS IMPROVES WITH
ADENOIDECTOMY
(?TONSILLECTOMY)
CAUSATIVE FACTORS
AIRWAY
POLLUTANTS:
MOST
PROMINENTLY
SECOND HAND
SMOKE
CAUSATIVE FACTORS
GERD: PROBABLY
BY CAUSING
ADENOIDITIS.
RECENT STUDY
BY PARSONS
SUGGESTED
SIGNIFICANT
CAUSATION.
CAUSATIVE FACTORS
STRUCTURAL
ABNORMALITIES:
DEVIATED SEPTUM
MAXILLARY SINUS
HYPOPLASIA
LATERAL WALL
ANOMALIES (HALLER
CELL, CONCHA
BULLOSA,
PARADOXICAL
MIDDLE TURBINATE)
CAUSATIVE FACTORS
PRIMARY
IMMUNODEFICIENCY (PID)
TRANSIENT
HYPOGAMMA
GLOBULINEMIA
IgG SUBCLASS
DEFICIENCY
OTHERS
CAUSATIVE FACTORS
PCD (PRIMARY
CILIARY
DYSKINESIA)--50% HAVE
KARTAGENER’S
SYNDROME
CAUSATIVE FACTORS
CYSTIC FIBROSISWITH NEWER
GENETIC TESTING
(CF MUTATION
ANALYSIS) WE
ARE ABLE TO
DIAGNOSE MANY
LESS SEVERE
VARIANTS
RHINOSINUSITIS
HOW DO YOU
DIAGNOSE IT?
HOW DO YOU
TREAT IT?
DIAGNOSIS
HISTORY
PHYSICAL
ENDOSCOPY
CT SCAN
DIAGNOSIS
MAJOR FACTORS
FACIAL
PAIN/PRESSURE
NAO
DISCHARGE
HYPOSMIA
PURULENCE
FEVER
MINOR FACTORS
HEADACHE
FEVER
HALITOSIS
FATIGUE
DENTAL PAIN
COUGH
AURAL
PAIN/FULLNESS
MAXIMAL MEDICAL
THERAPY
SALINE (SPRAY/IRRIGATIONS)—
HYPERTONIC?
DECONGESTANTS (TOPICAL/SYSTEMIC)
MUCOLYTICS
STEROIDS (TOPICAL/SYSTEMIC)
ANTIHISTAMINES (TOPICAL/SYSTEMIC)
REFLUX THERAPY?
MAXIMAL MEDICAL
LEUKOTRIENE INHIBITORS
ANTIBIOTICS (TOPICAL/SYSTEMIC)
USUALLY START TREATMENT
EMPIRICALLY---TREAT AT LEAST 1
WEEK PAST THE RESOLUTION OF
SYMPTOMS (OFTEN 20 DAYS)
 SINUNEB—IRRIGATIONS
 CHRONIC---LOW DOSE CHRONIC
BIAXIN

ALLERGY
THE NOSE IS THE TARGET ORGAN
FOR AEROALLERGENS, IRRITANTS,
AND DEBRIS.
TOPICAL THERAPIES AND NASAL
RINSES ARE PARAMOUNT.
ALLERGY
ALLERGY TESTING AND TREATMENT
IS NEVER A BAD IDEA PRIOR TO
SURGERY
IDT IS THE MOST SENSITIVE AND
SPECIFIC METHOD OF ALLERGY
TESTING
SURGERY
THE CHRONIC INFLAMMATION
FROM ALLERGIES AND INFECTIONS
CAN LEAD TO ANATOMIC CHANGES
SINONASAL INFECTION IS A
RELATIVE TERM
MOST MUCOSAL PROBLEMS ARE
REVERSIBLE
SINUS SURGERY IS PLAN C
SINUS SURGERY
WE DO IT BETTER--UTILILIZE LASERS,
ENDOSCOPES, TV
MONITORS,
MICRODEBIDERS,
COMPUTER
GUIDANCE SYSTEMS---STILL A DRAINAGE
PROCEDURE
FUNCTIONAL
IMAGE GUIDED
LASER AND POWERED
MINIMALLY INVASIVE